Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 12 May 2015. A breach of legal requirements was found. The breach related to a lack of effective auditing systems in place to ensure assessment, monitoring and driving improvements in the quality and safety of care and treatment provided. We had also found there was not an effective risk management system or process in place to assess, monitor and mitigate risks relating to the health, safety and welfare of people using the service and others. This included general environmental and health and safety risk assessments. Following the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the breach.

We undertook this focused inspection visit to check that the provider had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Westbrook Medical centre on our website at www.cqc.org.uk

During this follow up inspection visit we found a number of practices had been put in place to address the previously identified shortfalls;

• Auditing systems had been improved to monitor effectiveness and drive improvements to the quality and safety of care and treatment provided.

• Additional health and safety related checks and risk assessments had been introduced to assess, monitor and mitigate risks relating to people’s health, safety and welfare.

• Staff had been supported through appraisal and on going training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Westbrook Medical Centre on 12 May 2015. Overall the practice is rated as good.

Westbrook Medical Centre provided safe, effective, responsive care that addressed the needs of the population it served. Improvements were needed to ensure governance arrangements were effective.

Our key findings across all the areas we inspected were as follows:

• Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons learnt from the investigation of safety incidents were disseminated to staff. Infection risks and medicines were managed safely.

• Patients care needs were assessed and care and treatment was being considered in line with best practice national guidelines. Patients experienced clinical outcomes that were in line with or above the national average. Staff were proactive in promoting good health

• Patients spoke highly of the practice. They said they were treated with care, compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The practice provided care to its population that was responsive to their health needs. Patients were listened to and feedback was acted upon. Complaints were managed appropriately.

• There was an evident leadership structure, staff enjoyed working for the practice and felt well supported and valued. However improvements were needed to ensure audit and governance systems were effective and that systems were in place to identify, assess and mitigate risks.

There were areas of practice where the provider needs to make improvements.

The provider must:

• Implement effective audit and risk management systems and processes to ensure assessment, monitoring, mitigation of risks and improvements are made in the quality and safety of the services provided, including the quality of the experience of patients using the service.

In addition the provider should:

• Ensure its recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff and the required information in respect of workers is held. This should include obtaining information about any physical or mental health conditions which are relevant to the person’s role and photographic identification.
• Ensure that non-clinical staff are up to date with their appraisals and training in essential knowledge and skills for their role such as basic life support, infection control and safeguarding.
• Implement a system to ensure blank prescription forms are handled in accordance with national guidance and tracked through the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice